The Family Caregiver ConnectionSupporting Essential Care Partners as Patients Transition to Home

Danny van Leeuwen, RN, Health Hats

MaryAnne Sterling, CEA, Family Caregiver

Geri Lynn Baumblatt, MA, Patient Engagement Expert

Amy Cain, RN, Wolters Kluwer (Emmi)

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Elder Care Transitions = Sinking of Titanic

2018 © Sterling Health IT Consulting

My Mom’s Story• 7 care transitions in 4.5 months after a fall/

broken ankle • Every care transition means starting from

scratch • No communication or coordination between

facilities • Lack of a comprehensive care plan • Only source of up-to-date medication list =

me

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2018 © Sterling Health IT Consulting

What is a Care Transition?From To

• Hospital • In-patient Rehab • Assisted Living • Nursing Home • Hospice • Home

• Hospital • In-patient Rehab • Assisted Living • Nursing Home • Hospice • Home

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2018 © Sterling Health IT Consulting

What are the components of a care transition?• Change of physical location • Medical record updates • Medication changes/reconciliation • Coordination of healthcare • Coordination of social services • Instructions/next steps • New providers to educate • Paperwork • Family caregiver chaos

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2018 © Sterling Health IT Consulting

What makes elder care transitions unique?• Frail condition of many elders • Dementia & mobility issues • Medication volume and complexity • Living situations that don’t match care

needs • Fall risk • Patient wishes vs family preferences/

abilities • Driven by what Medicare will cover

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2018 © Sterling Health IT Consulting

What Happens Today?• Overall lack of knowledge about the needs of seniors with complex health conditions • Unique aspects of elder care transitions are not factored into the equation • Healthcare and social services operate in silos • Patients and family caregivers have to figure out how to navigate the system

on their own • Discharge instructions and medication lists are written at a high literacy level

and not user friendly • Many tasks previously designated for nurses are now being handed to family

caregivers • Longterm care is not tech enabled – at all.

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2018 © Sterling Health IT Consulting

What Does NOT Happen Today?• Communication • Care planning • Evaluation of family caregiver needs • Training for patients/family caregivers • Coordination of healthcare AND social services • Accountability/reliable follow-up • Treating the WHOLE patient

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Healthcare

Community Supports

Social Services

2018 © Sterling Health IT Consulting

Result for Caregivers• Absent from work trying to find resources & coordinate care ▫ Can’t find resources in their community ▫ Can’t afford resources they do find ▫ Can’t get access to medical records

• Not prepared or trained • Neglect their own health and end up needing care • Expend their own financial resources • High likelihood their parent will make return trip to emergency dept

and the process begins again…

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2018 © Sterling Health IT Consulting

What can the “system” do?• Guide family toward services they may need and help

coordinate them • Provide clinical information in a way both patient and

caregiver understand, i.e. plain language and language of choice

• Provide access to an aggregate medical record and assistance from a pharmacist to review & adjust medications

• Help put resources in place, starting with an on-call home health nurse

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Tools to Support the Circle of Care

Geri Lynn Baumblatt, MA @GeriLynn

Disclosures

Advisor, Roobrik

Advisor, Helpsy Health

Beta Tester, Atlas of Caregiving CareMap app

Consultant, Active Daily Living

Concerns• Safely providing care • Skills • Understanding • Finances

@gerilynn

@gerilynn

• Social Isolation • Family strife • Injuries to self • Care coordination • Their job/employment • Their health

What they don’t know…

1. Haley et al, 2009; 2 Cuijpers, 2005; 3. Girgis el al, 2013; 4. Spillman et al, 2014; 5, Slgado-Garcia et al 2015; 6. Dassell@ Carr, 2014 & Steinberg et al, 2010; 7 Darragh et al, 2015; 8. Capistrant 2012 $ Ji et al 2012; 9. George & Gwyther, 1986, Selzer & Li, 2000, Skaff & Perrin 1992; 10. Haley et al, 2009

@gerilynn

http://www.oncologynurseadvisor.com/oncology-nursing/including-informal-caregivers-in-discharge-planning-beneficial/article/651627/

Including Informal Caregivers of Elderly in Discharge Process Reduces Readmission Risk

25% reduced risk of readmit within 90 days

24% reduced risk of readmit within 180 days

@atlasofcare

lungchicago.org

lungchicago.org

@careDOTcoach

©2017.Allrightsreserved.

Example InteractionAvatar = human + software

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@careDOTcoach

©2017.Allrightsreserved.

The Avatar SolutionThe best of human & software intelligence

CORE

ProviderPortal

FamilyPortal

CareAvatar

HealthAdvocates

ClinicalAlgorithms

inpatientin-home

⬆self-management

⬇readmissions

⬇delirium⬇EDvisits/admissions

⬆wellness

⬆patientsatisfaction

⬇falls

⬆value-basedcare$$$coaching

observing reporting

engage

ment

24x7personalizedsupport

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@careDOTcoach

©2017.Allrightsreserved.

ROI from Avoiding ReadmissionDe-identified patient data shown

Email+phonealerttriggeredbycontextualresponse:

PreventedReadmission$13,000costavoidance

byinformingclinicalteamtoadjustmedications

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• Passively tracks day-to-day activity of the care recipient in their living space • Activity and inactivity compared against defined criteria and daily living patterns • If activity falls outside normal patterns, caregivers receive alerts

In-homecomponents Simplesetupwithtelephonesupport Smartphonedisplay

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CAPTURES INFORMATION • Motion • Door status • Bed/Chair occupied • Pill box access • Stove left on

ANALYZES DATA and compares to selected safety criteria

Caregivers Select Alert & Notification Criteria

Caregiver Installs DevicesCaregivers Receive

Actionable Information

SafeinHome

ALERTS Immediate Attention

OBSERVATION on Demand

Tracking of multiple days

activity

TREND ANALYSIS Identifies changes

71% of caregivers interested in technology

… only 7% use it

• Don’t know which tech to use • No time to learn new tech • Clinicians need to suggest friendly tech

AARP 2016

Why Not?

EmpoweringPatients&CaregiversAfterDischarge

Titleofpresentation

Inanidealworld–patientsandcaregiverswouldleaveanyepisodeofcare

understandingeverythingtheyneedtoknowtogetbetter,staywell,

attheirhighestleveloffunctionandhaveaccesstoallthetoolstheyneed

forsuccess.

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Titleofpresentation

TechnologytoMaintainConnection

▪ Keeppatientatthecenter▪ Drivepatientstotherightactions▪ Includefamilyandcaregivers▪ Personalized▪ Deliversconsistentmessageinreliablemanner▪ Deliversresultsforproviders

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Titleofpresentation

ExtendingReach

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Titleofpresentation

EmmiTransition®

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• Proactive,scalableandautomatedcallcampaigns• Helpspeopletransitionfromhospital-to-home• Reinforceskeymessagestoindividualsandfamily• Tracksanddocumentsactivityandrecovery• CorrespondingEmmiEngage®programs

EngageswithEmmi’sempatheticvoice

Collectsvitalinformationfromusers

Providesdailyreportsonrecoverystatus

NotifiesStaffofpeopleat-riskofreadmission

Titleofpresentation

UniqueApproach–UnderstandsPeople

BuiltonBehavioral&EducationalScience

▪ Triggers▪ Habits▪ Motivators▪ PositivePsychology▪ ActionPlanning

HumanCenteredDesign

▪ Intuitive▪ Non-disruptive▪ Empathetic▪ Normalize&De-stigmatize▪ ReduceAnxiety

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Ifyourdoctor’sofficecan’tgetyouinsoon,makesuretheyknowyouwerejustinthehospitalandweretoldyouhaveheartfailure.

PROPRIETARY & CONFIDENTIALPROPRIETARY & CONFIDENTIAL

Day 1

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Transportation to follow-up appointment?

Day 2

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HeartFailureHarry–45daysofconnection